Women and Newborn Health Service Neonatal Directorate

CLINICAL PRACTICE GUIDELINE Guideline coverage includes NICU KEMH, NICU PCH and NETS WA Calculator - Assessment of Early- Onset Sepsis in > 35 Weeks This document should be read in conjunction with the Disclaimer

Neonatal Sepsis Calculator  Neonatal Early-Onset Sepsis Calculator.  Set incidence to the KEMH rate of 0.4/1000 live births.  For indigenous infants, set the incidence to 1/1000 live births. Key Points  This guideline applies to all infants born at ≥ 35 weeks.  Three groups of infants require a blood culture and antibiotic treatment without delay:  Unwell appearing infants.  Infants whose sibling had EOS.  Infants whose mother currently has Group A Streptococcal infection.  Contact the on-call paediatric staff for any queries or concerns about an .  The EOS risk score should be documented on the neonatal history sheet by  Neonatal staff if baby admitted to neonatal unit  By the attending midwife if baby remains with mum  The EOS score should be calculated as early as possible after delivery, when first set of neonatal observations are available.  Document only the one EOS score applicable at the time of assessment. Definitions and Parameters used for Assessment of Risk for Neonatal Sepsis Information required for calculation of EOS score:  Gestational age.  Highest maternal antepartum temperature (ie between onset of labour to delivery). In case of precipitous delivery or BBA the first available temperature post delivery may be used.  Duration of rupture of membranes.  GBS status.  Maternal intrapartum antibiotics. Classification of maternal intravenous antibiotics:

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 GBS IAP: Penicillin, , Amoxicillin, , Erythromycin, Cefazolin, Vancomycin.  Broad-spectrum antibiotics: other , Fluoroquinolone, Piperacillin/Tazobactam, Meropenem or any combination of antibiotics that includes an or Metronidazole.

Newborn Clinical Presentation: The EOS risk score then incorporates the clinical presentation of the infant to determine the appropriate management plan. The newborn clinical presentation is assessed as:  Well appearing.  Equivocal signs.  Clinical illness.

Definition of Equivocal Clinical Signs Clinical Parameters Assessed Equivocal Signs  Heart rate > 160/min 2 clinical parameters abnormal for >2hrs  Respiratory rate > 60/min  Temperature > 38.0°C or <36.4°C or  Respiratory distress (grunting, 1 clinical parameter abnormal for 4hrs nasal flaring or costal recessions)

 Any infant with abnormal clinical parameters requires urgent paediatric review.  Any infant with equivocal signs requires observation in the neonatal unit.

Clinical Illness  Unwell babies will be managed in the neonatal unit. Interpretation of EOS Risk Score Results and Infant Management

Management Plan for GREEN Group:  Routine care.  Early discharge possible.

Management Plan for YELLOW Group:  Require: BLOOD CULTURE AND OBSERVATION.  Occasionally, with borderline elevated risk the EOS calculator may indicate ‘Yellow – observation only’. Please follow those recommendations.  No routine full blood count or CRP.  Infants with equivocal signs require observation in the neonatal unit; when signs have normalised.  Observations (3 hourly vital signs) may continue on the postnatal wards until blood culture result available.  Infants with medium risk, but normal exam may be observed (3 hourly vital signs) on postnatal wards until blood culture result available.

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Sepsis Calculator - Assessment of Early-Onset Sepsis in Infants > 35 Weeks

 If abnormal clinical parameters develop, the infant requires urgent paediatric review.  If equivocal signs develop, infant requires transfer to neonatal unit.

Management Plan for RED Group:  TAKE BLOOD CULTURE AND TREAT WITH EMPIRIC ANTIBIOTICS.  For details, see sepsis treatment guideline and antibiotic monographs.  With the blood culture, take full blood count and CRP.  Repeat CRP next morning (usually no earlier than 8-12 hours after first CRP).  Unwell infants and those with equivocal signs will be treated in the neonatal unit until stable and may then continue treatment and observation on the postnatal wards.  Well infants requiring antibiotics may be treated on the postnatal wards and require 3 hourly vital signs until blood culture result available.

Documentation of EOS Risk and Clinical Assessment in Medical Notes  One EOS score after clinical exam should be documented on the neonatal history form:  Date/time.  ‘EOS risk score: [insert calculated score]’.  Management category, i.e. green, yellow or red.  If the EOS risk score was not completed in the birth room/theatre, then this should be performed at the earliest opportunity and the result documented as above.  Infant management plan, based on the EOS risk score and current clinical presentation needs to be documented in the medical notes.  If baby’s clinical presentation changes, the overall EOS risk score and the appropriate management plan may change and this needs to be documented in the medical notes.

Ceasing antibiotics for >35 weeks infants who are well with a normal CRP (x2)  Antibiotics may be stopped and baby discharged at 36 hours if blood culture are negative so far (in daytime hours)5.  After hours it is not possible to ensure a negative culture - so need to wait to confirm.  If a blood culture becomes positive after 36 hours and the baby has been discharged appropriate review may occur in ED as necessary.

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Sepsis Calculator - Assessment of Early-Onset Sepsis in Infants > 35 Weeks

References

1. Escobar GJ, Puopolo KM, Wi S, Turk BJ, Kuzniewicz MW, Walsh EM, Newman TB, Zupancic J, Lieberman E, Draper D: Stratifi- cation of risk of early-onset sepsis in newborns ≥34 weeks’ gestation. 2014; 133:30–36. 2. Kuzniewicz MW, Puopolo KM, Fischer A, Walsh EM, Li S, Newman TB, Kipnis P, Esco- bar GJ: A quantitative, risk-based approach to the management of neonatal early-onset sepsis. JAMA Pediatr 2017;171:365–371. 3. Puopolo KM, Draper D, Wi S, Newman TB, Zupancic J, Lieberman E, Smith M, Escobar GJ: Estimating the probability of neonatal early-onset infection on the basis of maternal risk factors. Pediatrics 2011;128:e1155– e1163. 4. Strunk T, Buchiboyina A, Sharp M, Nathan E, Doherty D, Patole S. Implementation of the Neonatal Sepsis Calculator in an Australian Tertiary Perinatal Centre. . 2018;113(4):379-382. doi: 10.1159/000487298. 5. NICE clinical guideline. Neonatal sepsis

Related WNHS policies, procedures and guidelines

Neonatal Early-Onset Sepsis Calculator

Document owner: Neonatal Directorate Management Committee Author / Reviewer: Neonatal Directorate Management Committee Date first issued: March 2016 Last reviewed: 18th January 2019 Next review date: 18th January 2022 Endorsed by: Neonatal Directorate Date endorsed: 26th February 2019 Management Committee Amendment: 11th March 2019 Date endorsed: 26th March 2019

Standards NSQHS Standards: 1 Governance, 3 Infection Control, 8 Acute Applicable: Deterioration Printed or personally saved electronic copies of this document are considered uncontrolled. Access the current version from the WNHS website.

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